| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
99 |
99 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
14 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
15 |
$2K |
| D1120 |
Prophylaxis - child |
54 |
54 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
153 |
153 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
221 |
129 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$990.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$272.80 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$110.00 |